Date: 4/18/2014

Application Form

Synergy HomeCare of Minneapolis

THANK YOU FOR APPLYING WITH SYNERGY HOMECARE IN GOLDEN VALLEY. OUR TERRITORIES ARE IN THE FOLLOWING CITIES: OSSEO, BROOKLYN PARK, MAPLE GROVE, NEW HOPE, PLYMOUTH, GOLDEN VALLEY, WAYZATA, MINNETONKA, CHANHASSEN, CHASKA, EXCELSIOR, HOPKINS, EDEN PRAIRIE, MOUND, SAVAGE, SHAKOPEE, SPRING PARK, VICTORIA, ST. LOUIS PARK.

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - General Information

Number Question Effective Date Expiration Date
1 Today's Date (required)  
     
2 Where did you hear about Synergy HomeCare? (required)  
 
3 Can you provide documentation of a driver's license and auto insurance? (required)  
     
4 Are you covered by auto liability insurance? (required)  
     
5 Do you have a reliable means of transportation? (required)  
     
6 Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)  
     
7 If yes, please explain.  
 
8 Have you ever been convicted of a felony? (required)  
     
9 If yes, please explain.  
     
10 Have you ever been released from a job due to discipline or being fired? (required)  
     
11 If yes, please explain.  
     
12 What ad are you responding to? What position? What location? (required)  
     
13 Please list the days and hours you are looking for work and when you would be available to start? (required)  
     
14 Please explain why you are interested in Home Care and why you feel you would be or are good at it. (required)  
 
15 How Far are you willing to travel from your home to a clients home to provide service (required)  
  (Numeric Answer Only)    
16 Are you willing to work short shifts (1-2)hrs (required)  
     
17 Are you willing to work 24-hour shift (required)  
     

Section 2 - Employment Verification

Number Question Effective Date Expiration Date
1 Are you a U.S. citizen? (required)  
     
2 If you are not a U.S. citizen, please indicate VISA type and number.  
     
3 Can you submit verification of your legal right to work in the U.S.? (required)  
     

Section 3 - Education

Number Question Effective Date Expiration Date
1 Name of High School: (required)  
     
2 Location of High School: (required)  
     
3 Did you graduate? (required)  
     
4 Years Attended (From/To): (required)  
     
5 Did you attend College? (required)  
     
6 If yes, please list the name of the school and years attended, (From/To)and degree  
 

Section 4 - Other Training: Certifications/Licenses

Number Question Effective Date Expiration Date
1 Please select all certifications you currently have (required)  
 
 
 
 
 

Section 5 - Current/Last Employment

Number Question Effective Date Expiration Date
1 Company Name (required)  
     
2 Address: (required)  
     
3 City: (required)  
     
4 State: (required)  
     
5 Zip Code: (required)  
     
6 Start Date: (required)  
     
7 End Date: (required)  
     
8 Hours Worked: (required)  
 
 
 
9 Position/Title: (required)  
     
10 Describe Your Responsibilities: (required)  
 
11 Supervisor's Name/Title: (required)  
     
12 Supervisor's Phone:  
     
13 Reason for Leaving: (required)  
 
14 May we contact? (required)  
     

Section 6 - Employment History

Number Question Effective Date Expiration Date
1 Company Name (required)  
     
2. Address: (required)  
     
3. City: (required)  
     
4. State: (required)  
     
5. Zip Code: (required)  
     
6. Start Date: (required)  
     
7. End Date: (required)  
     
8. Hours Worked: (required)  
 
 
 
9. Position/Title: (required)  
     
10. Describe Your Responsibilities: (required)  
 
11. Supervisor's Name/Title: (required)  
     
12. Supervisor's Phone: (required)  
     
13. Reason for Leaving: (required)  
 
14. May we contact? (required)  
     

Section 7 - Personal References (3)

Number Question Effective Date Expiration Date
1 Name: (required)  
     
2 Relationship (required)  
     
3 Phone: (required)  
     
4 Name (required)  
     
5 Relationship (required)  
     
6 Phone (required)  
     
7 Name (required)  
     
8 Relationship (required)  
     
9 Phone (required)  
     

Section 8 - Employment References (3)

Number Question Effective Date Expiration Date
1 Name of Human Resources Professional (required)  
     
2 Company Name (required)  
     
3 Human Resources Phone (required)  
     
4 Name of Human Resources Professional (required)  
     
5 Company Name (required)  
     
6 Human Resources Phone (required)  
     
7 Name of Human Resources Professional (required)  
     
8 Company Name (required)  
     
9 Human Resource Phone (required)  
     

Section 9 - Emergency Contact Information

Number Question Effective Date Expiration Date
1. First Name: (required)  
     
2. Last Name: (required)  
     
3. Address:  
     
4. City:  
     
5. State:  
     
6. Zip Code:  
     
7. Phone 1: (required)  
     
8. Phone 2:  
     
9. Relationship: (required)  
     



I hereby certify that the answers given by me to all the questions contained on this application form are true and correct to the best of my knowledge. If employed by Synergy HomeCare, I will comply with all rules and regulations of the company. I agree to submit to a physical and or drug examination if required. I also authorize my former employers to give any information they have regarding me to Synergy HomeCare, whether or not it is on their records. I authorize Synergy HomeCare to conduct any background checks necessary including, but not limited to: Felony and misdemeanor convictions, previous arrest history, and driving records (DVM). I hereby release Synergy HomeCare from all liability for and damage whatsoever for issuing the same. I understand that if any fraudulent information is given on this application, it will be grounds for immediate termination from my position. Synergy HomeCare is an egual Opportunity Employer. I understand that the job positions are placed equally without discrimination because of race, creed, color, religion, sex, national origin, sexual preference, handicap, or age.